Clinical observation of extremely elevated erythrocyte sedimentation rate / 中华危重病急救医学

Objective:To analyze the clinical features of adult patients with extremely elevated erythrocyte sedimentation rate (ESR, ESR≥100 mm/1 h), so as improve the ability of clinicians to use erythrocyte sedimentation rate to assist in the diagnosis and treatment of diseases.Methods:A retrospective cohort study was conducted to examine the clinical data of patients with ESR ≥ 100 mm/1 h admitted to the First Affiliated Hospital of Kunming Medical University from January 1st 2019 to December 31st 2019. The age, gender, clinical diagnosis, first ESR level after admission, blood routine, liver function, renal function, coagulation function and C-reactive protein (CRP) within 24 hours after admission were collected. Patient cohorts were divided into youth group (18-65 years old), middle-aged group (66-79 years old) and elderly group (≥80 years old) according to the new standards of human age classification of World Health Organization (WHO) 2019. Patient cohorts were also divided into infectious disease group, hematological disease group, autoimmune disease group, renal failure group and others according to their respective clinical diagnosis. The distribution of extremely elevated ESR in each group, and the correlation between ESR and various laboratory indicators were analyzed.Results:① Among 429 patients with ESR≥ 100 mm/1 h, there were 236 males and 193 females. There was no significant difference in ESR levels between males and females [mm/1 h: 108.00 (103.00, 119.75) vs. 117.00 (105.50, 140.00), P = 0.234]. ② The age of 429 patients ranged from 18 to 98 years old, the average age was (53.70±18.70) years old. There were 310 cases in the youth group, 87 cases in the middle-aged group and 32 cases in the elderly group. The ESR level of the young group was significantly lower than that of the middle-aged group and the elderly group [mm/1 h: 108.00 (103.00, 120.00) vs. 119.00 (107.00, 140.00), 120.00 (110.25, 140.00), both P < 0.01]. ③ The main diagnoses associated with extremely elevated ESR were infectious diseases [157 cases (36.6%)], hematological system diseases [127 cases (29.6%)], autoimmune diseases [74 cases (17.2%)]. Pulmonary infection accounted for 58.0% (91/157) of infectious diseases. Hematopoietic stem cell diseases accounted for 45.7% (58/127), lymphocyte and plasma cell diseases accounted for [37.0% (47/127)] and erythrocyte diseases accounted for [11.0% (14/127)] of the hematological system diseases. Diffuse connective tissue diseases accounted for 75.7% (56/74) of autoimmune diseases. ④ Spearman correlation analysis showed that the extremely elevated ESR in all patients was significantly negatively correlated with the levels of red blood cell count (RBC), hemoglobin (HB) and hematocrit (HCT) (ρvalue was -0.395, -0.381 and -0.383, respectively, all P < 0.01), the ESR was significantly positively correlated with the level of fibrinogen (FIB; ρ= 0.345, P < 0.01). A total of 266 patients were tested for both ESR and CRP, and there was no significantly correlation between ESR and CRP level (ρ= -0.019, P = 0.756). Conclusions:The extremely elevated ESR was more common in pulmonary infections diseases, hematopoietic stem cell diseases, lymphocyte and plasma cell diseases, erythrocyte diseases and diffuse connective tissue diseases. The extremely elevated ESR was significantly correlated with the levels of RBC, HB, HCT and FIB.

Adherence to adjuvant with therapy imatinib in patients with gastrointestinal stromal tumor: a national multi-center cross-sectional study / 中华胃肠外科杂志

Objective: To analyze the current adherence to imatinib in patients with gastrointestinal stromal tumors (GIST) in China and its influencing factors. Methods: A cross-sectional survey was conducted. Study period: from October 1, 2020 to November 31, 2020. Study subjects: GIST patients taking imatinib who were diagnosed and treated in public tertiary level A general hospitals or oncology hospitals; those who had not been pathologically diagnosed, those who never received imatinib, or those who had taken imatinib in the past but stopped afterwards were excluded. The Questionnaire Star online surgery platform was used to design a questionnaire about the adherence to adjuvant imatinib therapy of Chinese GIST patients. The link of questionnaire was sent through WeChat. The questionnaire contained basic information of patients, medication status and Morisky Medication Adherence Scale. Results: A total of 2162 questionnaires from 31 provinces, autonomous regions, and municipalities were collected, of which 2005 were valid questionnaires, with an effective rate of 92.7%. The survey subjects included 1104 males and 901 females, with a median age of 56 (22-91) years old. Working status: 609 cases (30.4%) in the work unit, 729 cases (36.4%) of retirement, 667 cases of flexible employment or unemployment (33.3%). Education level: 477 cases (23.8%) with bachelor degree or above, 658 cases (32.8%) of high school, 782 cases (39.0%) of elementary or junior high school, 88 cases (4.4%) without education. Marital status: 1789 cases (89.2%) were married, 179 cases (8.9%) divorced or widowed, 37 cases (1.8%) unmarried. Two hundred and ninety-four patients (14.7%) had metastasis when they were first diagnosed, including 203 liver metastases, 52 peritoneal metastases, and 39 other metastases. One thousand eight hundred and sixty-nine patients underwent surgical treatment, of whom 1642 (81.9%) achieved complete resection. The median time of taking imatinib was 25 (1-200) months. Common adverse reactions of imatinib included 1701 cases (84.8%) of periorbital edema, 1031 cases (51.4%) of leukopenia, 948 cases (47.3%) of fatigue, 781 cases (39.0%) of nausea and vomiting, 709 cases (35.4%) of rash, and 670 cases (33.4%) of lower extremity edema. The score of the Morisky Medication Adherence Scale showed that 392 cases (19.6%) had poor adherence, 1023 cases (51.0%) had moderate adherence, and 590 cases (29.4%) had good adherence. Univariate analysis showed that gender, age, work status, economic income, residence, education level, marriage, the duration of taking medication and adverse reactions were associated with adherence to adjuvant imatinib therapy (all P<0.05). Multivariate analysis showed that female (OR=1.264, P=0.009), non-retirement (OR=1.454, P=0.001), monthly income ≤4000 yuan (OR=1.280, P=0.036), township residents (OR=1.332, P=0.005), unmarried or divorced or widowed (OR=1.362, P=0.026), the duration of imatinib medication >36 months (OR=1.478, P<0.001) and adverse reactions (OR=1.719, P=0.048) were independent risk factors for poor adherence to adjuvant imatinib. Among patients undergoing complete resection, 324 (19.7%) had poor adherence, 836 (50.9%) had moderate adherence, and 482 (29.4%) had good adherence. Meanwhile, 55 patients with good adherence (11.4%) developed recurrence after surgery, 121 patients with moderate adherence (14.5%) developed recurrence, 61 patients with poor adherence (18.8%) developed recurrence, and the difference was statistically significant (P=0.017). Conclusions: The adherence to adjuvant therapy with imatinib in Chinese GIST patients is relatively poor. Females, non-retirement, monthly income ≤4000 yuan, township residents, unmarried or divorced or widowed, the duration of imatinib medication >36 months, and adverse reactions are independently associated with poor adherence of GIST patients. Those with poor adherence have a higher risk of recurrence after surgery. Positive interventions based on the above risk factors are advocated to improve the prognosis of patients with GIST.

Clinical analysis of 32 adult patients with infection-associated hemophagocytic syndrome / 中华危重病急救医学

Objective:To analyze the clinical feature of adult patients with infection-associated hemophagocytic syndrome (IAHS), and to improve the ability of clinicians to diagnose and treat IAHS.Methods:A retrospectively study was performed. The clinical data of 32 adult patients with IAHS admitted to the intensive care unit (ICU) of the First Affiliated Hospital of Kunming Medical University from July 2014 to November 2019 were analyzed. The general data, clinical manifestations, laboratory results, imaging findings, pathogen and clinical outcomes were collected, and the patients were divided into survival group and death group according to the 28-day prognosis. The clinical data between the two groups were compared, and multivariate Logistic regression analysis was used to analyze the variables with statistical significance in univariate analysis. The receiver operating characteristic (ROC) curve was drawn to analyze the predictive value of variables with statistical significance in univariate analysis for 28-day prognosis of adult patients with IAHS.Results:Among 32 adult patients with IAHS, there were 17 males (53.1%) and 15 females (46.9%). Eighteen patients were bacterial infection, most of which were Acinetobacter baumannii and Escherichia coli; 14 patients were viral infection, mainly EB virus; and the overall 28-day mortality was 62.5% (20/32). ① Compared with the survival group ( n = 12), the levels of white blood cell (WBC), neutrocyte (NEU), lymphocyte (LYM), platelet (PLT) and oxygenation index (OI) in the death group ( n = 20) were lower, while the levels of aspartate aminotransferase (AST), K +, serum ferritin (SF) and lactate dehydrogenase (LDH) were higher [WBC (×10 9/L): 3.90±3.36 vs. 9.57±6.48, NEU (×10 9/L): 2.69±2.09 vs. 7.01±6.34, LYM (×10 9/L): 0.36 (0.23, 0.84) vs. 1.24 (0.61, 2.36), PLT (×10 9/L): 51.15±27.60 vs. 108.42±80.26, OI (mmHg, 1 mmHg = 0.133 kPa): 134.0 (77.5, 192.0) vs. 292.0 (187.0, 329.0), AST (U/L): 254.00 (67.80, 452.50) vs. 85.50 (38.38, 111.25), K + (mmol/L): 4.06 (3.65, 4.51) vs. 3.52 (3.26, 3.76), SF (μg/L): 6 290.0 (1 851.0, 13 904.8) vs. 1 777.1 (1 228.5, 3 486.3), LDH (μmol·s -1·L -1): 19.3 (11.9, 27.0) vs. 9.8 (6.9, 11.1), all P < 0.05]. In death group, duration of having a fever after admission was prolonged [days: 13.5 (9.0, 17.2) vs. 6.0 (2.5, 8.0), P < 0.05] and the incidence of cyanosis was higher (40.0% vs. 0%, P < 0.05). There was no significant difference in other indicators between the two groups. ② Multivariate Logistic regression analysis showed that low OI combined with high LDH were risk factors for 28-day mortality of adult patients with IAHS [odds ratio ( OR) was 0.967 and 1.007, respectively, both P < 0.05].③ It was shown by ROC curve analysis that WBC, NEU, AST, SF, LDH and OI had predictive value for 28-day prognosis of adult patients with IAHS (both P < 0.05), and the area under ROC curve (AUC) of OI and LDH was higher, that was both 0.847. When the best cut-off of OI was 145.5 mmHg, the sensitivity was 63.2%, and the specificity was 100%. When the best cut-off of LDH was 13.4 μmol·s -1·L -1, the sensitivity was 72.2%, and the specificity was 91.7%. Conclusion:OI < 145.5 mmHg, and LDH > 13.4 μmol·s -1·L -1 were significant predictors for poor 28-day prognosis of adult patients with IAHS.

Feasibility of difference between hematocrit and albumin for identifying severity of scrub typhus disease / 中华危重病急救医学

Objective To explore the feasibility of difference between hematocrit and albumin (HCT-ALB) to evaluate the severity in patients with severe scrub typhus (Tsutsugamushi disease). Methods The clinical data of 408 patients with scrub typhus in 37 hospitals located in 15 prefectures of Yunnan Province from January 1st, 2017 to December 31st, 2018 were retrospectively collected. The patients were divided into the non-severe scrub typhus disease group (n = 265) and the severe scrub typhus disease group (n = 143) according to the diagnostic criteria. Volunteers attending Kunming City Medical Center in Yunnan Province for routine physical examination were enrolled as healthy control group (n = 230). HCT, ALB, lactate dehydrogenase (LDH), uric acid (UA), and acute physiology and chronic health evaluationsⅡ(APACHEⅡ) and sequential organ failure assessment (SOFA) within 24 hours after admission were collected. HCT-ALB difference was calculated. Pearson method was used to analyze the correlation between HCT-ALB difference and LDH, UA, APACHEⅡ and SOFA scores in patients with severe scrub typhus disease; the receiver operating characteristic (ROC) curve was used to analyze the value of HCT-ALB difference in the diagnosis of severe scrub typhus disease. Results ① There was no significant difference in gender composition between patients with non-severe scrub typhus disease group and severe scrub typhus disease group, but the age of the severe scrub typhus disease group was significantly higher than that of the non-severe scrub typhus disease group (years old: 53.57±15.23 vs. 35.03±23.47, P < 0.01). ② Compared with the healthy control group, the HCT, ALB of the non-severe scrub typhus disease group and severe scrub typhus disease group were significantly decreased [HCT: (36.54±6.82)％, (38.13±7.60)％vs. (46.20±4.42)％; ALB (g/L): 35.53±5.87, 26.90±6.10 vs. 47.75±4.28, all P < 0.01], and the HCT-ALB difference was significantly increased (5.28±3.90, 11.26±6.62 vs. 1.55±5.32, both P < 0.01). Compared with the non-severe scrub typhus disease group, the HCT of the severe scrub typhus disease group was significantly increased [(38.13±7.60)％vs. (36.54±6.82)％, P < 0.01], the ALB was significantly decreased (g/L: 26.90±6.10 vs. 35.53±5.87, P < 0.01), and the HCT-ALB difference was significantly increased (11.26±6.62 vs. 5.28±3.90, P < 0.01). ③ Pearson correlation analysis showed that HCT-ALB difference was positively correlated with LDH and UA in patients with severe scrub typhus disease (r values were 0.316 and 0.284, respectively, both P < 0.01), and negatively correlated with APACHEⅡ score and SOFA score (r values were -0.229 and -0.198, respectively, both P < 0.05). ④ ROC curve analysis showed that the area under the curve (AUC) of HCT-ALB difference in the diagnosis of severe scrub typhus disease was 0.786, standard error was 0.024, P = 0.000, and 95％ confidence interval (95％CI) was 0.739-0.832. When the best diagnostic value was 8.56, the sensitivity was 81.1％, the specificity was 60.8％, and the Youden index was 0.419. Conclusions HCT-ALB difference is an indicator to evaluate the severe scrub typhus disease. When HCT-ALB difference is above 8.56, it can be used as an indicator to identify severe scrub typhus disease.

Feasibility of difference between hematocrit and albumin for identifying severity of scrub typhus disease / 中华危重病急救医学

Objective@#To explore the feasibility of difference between hematocrit and albumin (HCT-ALB) to evaluate the severity in patients with severe scrub typhus (Tsutsugamushi disease).@*Methods@#The clinical data of 408 patients with scrub typhus in 37 hospitals located in 15 prefectures of Yunnan Province from January 1st, 2017 to December 31st, 2018 were retrospectively collected. The patients were divided into the non-severe scrub typhus disease group (n = 265) and the severe scrub typhus disease group (n = 143) according to the diagnostic criteria. Volunteers attending Kunming City Medical Center in Yunnan Province for routine physical examination were enrolled as healthy control group (n = 230). HCT, ALB, lactate dehydrogenase (LDH), uric acid (UA), and acute physiology and chronic health evaluationsⅡ(APACHEⅡ) and sequential organ failure assessment (SOFA) within 24 hours after admission were collected. HCT-ALB difference was calculated. Pearson method was used to analyze the correlation between HCT-ALB difference and LDH, UA, APACHEⅡ and SOFA scores in patients with severe scrub typhus disease; the receiver operating characteristic (ROC) curve was used to analyze the value of HCT-ALB difference in the diagnosis of severe scrub typhus disease.@*Results@#① There was no significant difference in gender composition between patients with non-severe scrub typhus disease group and severe scrub typhus disease group, but the age of the severe scrub typhus disease group was significantly higher than that of the non-severe scrub typhus disease group (years old: 53.57±15.23 vs. 35.03±23.47, P < 0.01). ② Compared with the healthy control group, the HCT, ALB of the non-severe scrub typhus disease group and severe scrub typhus disease group were significantly decreased [HCT: (36.54±6.82)%, (38.13±7.60)% vs. (46.20±4.42)%; ALB (g/L): 35.53±5.87, 26.90±6.10 vs. 47.75±4.28, all P < 0.01], and the HCT-ALB difference was significantly increased (5.28±3.90, 11.26±6.62 vs. 1.55±5.32, both P < 0.01). Compared with the non-severe scrub typhus disease group, the HCT of the severe scrub typhus disease group was significantly increased [(38.13±7.60)% vs. (36.54±6.82)%, P < 0.01], the ALB was significantly decreased (g/L: 26.90±6.10 vs. 35.53±5.87, P < 0.01), and the HCT-ALB difference was significantly increased (11.26±6.62 vs. 5.28±3.90, P < 0.01). ③ Pearson correlation analysis showed that HCT-ALB difference was positively correlated with LDH and UA in patients with severe scrub typhus disease (r values were 0.316 and 0.284, respectively, both P < 0.01), and negatively correlated with APACHEⅡ score and SOFA score (r values were -0.229 and -0.198, respectively, both P < 0.05). ④ ROC curve analysis showed that the area under the curve (AUC) of HCT-ALB difference in the diagnosis of severe scrub typhus disease was 0.786, standard error was 0.024, P = 0.000, and 95% confidence interval (95%CI) was 0.739-0.832. When the best diagnostic value was 8.56, the sensitivity was 81.1%, the specificity was 60.8%, and the Youden index was 0.419.@*Conclusions@#HCT-ALB difference is an indicator to evaluate the severe scrub typhus disease. When HCT-ALB difference is above 8.56, it can be used as an indicator to identify severe scrub typhus disease.

Analysis of the clinical characteristics of severe tsutsugamushi disease in Yunnan Province from 2017 to 2018 / 中华危重病急救医学

To analyze the clinical characteristics of severe tsutsugamushi disease, and to improve the ability of clinicians to recognize severe cases. Methods The clinical data of patients with tsutsugamushi disease from January 1st, 2017 to December 31st, 2018 in hospitals of Yunnan Province were retrospectively collected by the Case Report Form (CRF). The age, gender, clinical symptoms at admission; white blood cell (WBC), eosinophil count (EO), red blood cell (RBC), platelet count (PLT), hemoglobin (Hb), hematocrit (HCT), albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBil), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), serum creatinine (SCr), uric acid (UA) on the first day of admission; and clinical outcomes were recorded. The patients were divided into the non-critical group and the critical group according to the diagnostic criteria, the data of clinical manifestation, laboratory examination, imaging examination and prognosis were compared between the two groups. Multivariate Logistic regression analysis was performed on the variables with statistical significance. The receiver operating characteristic (ROC) curve of LDH and UA for differential diagnosis of severe tsutsugamushi disease were drawn. Results From January 1st, 2017 to December 31st, 2018, 408 patients with tsutsugamushi disease were enrolled in 37 hospitals in 15 prefectures and municipalities of Yunnan Province. 385 cases were clinically diagnosed and 23 cases were laboratory diagnosed. There were 265 cases in non-critical group and 143 cases in critical group. A total of 8 cases died and the remaining 400 cases were discharged from hospital. ① Compared with the non-critical group, age of the critical group was older, the incidence of dizziness, cough, expectoration, general soreness, dyspnea, palpitation, abdominal pain, diarrhea, bulbar conjunctival congestion, pleural effusion, peritoneal effusion, pericardial effusion, hepatomegaly, splenomegaly, and the levels of WBC, ALT, AST, LDH, TBil, BUN, SCr, UA were significantly increased, the incidence of lymph node enlargement and the levels of EO, PLT and ALB were significantly decreased, and there was no significant difference in other indicators between the two groups.② Multivariate Logistic regression analysis showed that age, dyspnea, palpitations, LDH, UA, ALB were risk factors for severe tsutsugamushi disease, βvalue was 0.040,-2.147,-1.414, 0.002, 0.005 and-0.132 respectively, and the odds ratio (OR) was 1.041, 0.117, 0.243, 1.002, 1.005 and 0.877 respectively (all P < 0.01). ③ROC curve analysis showed that UA and LDH had better accuracy in differential diagnosis of severe tsutsugamushi disease (both P < 0.01), and the area under ROC curve (AUC) was 0.693 [95% confidence interval (95%CI) = 0.633-0.754], 0.819 (95%CI = 0.776-0.862), respectively. When the cut-off of UA was 306.2 μmol/L, the sensitivity was 60.8%, and the specificity was 77.4%. When the cut-off of LDH was 485.5 U/L, the sensitivity was 74.8%, and the specificity was 74.7%. The diagnostic value of UA combined with LDH was higher, AUC was 0.832, the sensitivity was 69.9%, and the specificity was 85.3%. Conclusion Severe tsutsugamushi disease can be diagnosed at an early stage according to age, respiratory distress, palpitations, hypoalbuminemia, UA >306.2 μmol/L, and LDH > 485.5 U/L.

The strategy of isolated complete resection of the caudate lobe of the liver through the anterior liver-splitting approach: a report of 19 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the strategy of isolated complete resection of the caudate lobe of the liver through the anterior liver-splitting approach.</p><p><b>METHODS</b>From January 1995 to June 2006, isolated complete caudate resection of the caudate lobe of the liver through the anterior liver-splitting approach in which accessed the caudate lobe by separation the liver parenchyma along the interlobar plane, was performed on 19 patients with tumors originated in caudate lobe. They were included hepatocellular carcinoma in 13 cases, cholangiocarcinoma in 4 cases and hemangioma in 2 cases, the tumor size range from 4 - 12 cm. The approach to hepatic resection involved routine use of Peng's multifunctional operative dissector, inflow and outflow of hepatic vascular control before hepatic parenchyma transection, low central venous pressure and selective use of liver hanging maneuver, as well as retrograde caudate lobectomy.</p><p><b>RESULTS</b>The operations were successful in 19 patients. Operating time averaged at (296 +/- 55) min. The average amount of blood loss were 1200 ml (ranged from 500 - 3000 ml). Postoperative complications included ascites in 2 cases, pleural effusion in 5 cases and bile leakage in 2 cases. They were cured by drainage. No mortality occurred in the perioperative period.</p><p><b>CONCLUSIONS</b>The application of anterior approach for isolated caudate lobectomy can converse certain kind of caudate lobe tumor from non-resectable to respectable resulting in widening the indication. The intraoperative routine use of Peng's multifunctional operative dissector, application of inflow and outflow of hepatic vascular control, low central venous pressure and selective use of liver hanging maneuver, as well as retrograde caudate lobectomy make the anterior liver-splitting approach for isolated complete caudate lobectomy safer and easier.</p>

Role of pancreatic hilar vascular occlusion in sophisticated pancreaticoduodenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the value of a simple occlusive technique of the triple vessels, ie, portal vein, superior mesenteric vessels and splenic vein, in complicated pancreaticoduodenectomy.</p><p><b>METHODS</b>The technique was fulfilled with a No.8 urethral catheter to encycle the portal vein, superior mesenteric vessels and its near tissue plus pancreatic tail and splenic vein than the neck of pancreas was transected and well exposure superior mesenteric vein and complete transaction of uncinate. From November 2005 to November 2006 the technique was applied to 12 cases of pancreatic malignancy which presented very infiltrated and adhesive to the hilar vascular structure.</p><p><b>RESULTS</b>The 12 cases were accomplished according with this technique. The operating time was (292.4 +/- 36.3) min (270 - 390 min) and the intraoperative blood loss was (833.3 +/- 618.4) ml (300 - 2500 ml). The postoperative complication included one case of lymphatic leakage, two cases of pneumonia, one case of abdominal infection and two cases of wound infection. There was no perioperative mortality. The postoperative hospital stay was 17 d (11 - 29 d).</p><p><b>CONCLUSIONS</b>Use this triple vessels occlusive technique can improve the safety and feasibility in complicated cases of pancreaticoduodenectomy.</p>

Surgical treatment of hepatocellular carcinoma with tumor thrombus in inferior vena cava / 中华外科杂志

<p><b>OBJECTIVE</b>To review the experience for the management of hepatocellular carcinoma with tumor thrombus in inferior vena cava.</p><p><b>METHODS</b>From July 2003 to May 2005, hepatectomy combined with thrombectomy were performed on 7 cases of hepatocellular carcinoma with tumor thrombus in inferior vena cava. In order to remove the tumor thrombus in inferior vena cava, total hepatic vascular exclusion were adopted on all cases to control the blood flow of IVC. According to the position of extension of tumor thrombus, 5 different procedures were adopted in the cases to control the suprahepatic IVC and extract the tumor thrombus out of IVC and atrium. Procedure 1: Median sternotomy, extracorporeal bypass, cardiac arrest, incision on right atrium and IVC were performed on 1 case for thrombectomy. Procedure 2: Median sternotomy, extracorporeal bypass without cardiac arrest, incision on IVC and (or without) incision on right atrium were performed on 2 cases for thrombectomy. Procedure 3: Abdominal approach to control intrapericardial IVC through an incision on diaphragm was performed on 1 case for thrombectomy. Procedure 4: Abdominal approach to control suprahepatic IVC above diaphragm through a small incision made on vena cava foramen for thrombectomy was performed on 1 case. Procedure 5: Abdominal approaches to control suprahepatic IVC below diaphragm for thrombectomy were performed on 2 cases.</p><p><b>RESULTS</b>All operations were successfully performed. The postoperative complications included pleural effusion in 1 case, subphrenic fluid collection in 1 case and wound infection in 1 case. The average survival time of 7 cases was 9.8 month. The longest survival time was 26 months.</p><p><b>CONCLUSION</b>Hepatectomy and thrombectomy can be safely performed on the case of HCC combined with tumor thrombus in IVC. Surgical treatment can relieve the patient from the risk of sudden death caused by heart failure and pulmonary.</p>

Surgical treatment of hepatocellular carcinoma originating from caudate lobe / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the significance of surgical treatment of HCC originating from caudate lobe.</p><p><b>METHODS</b>From 1995 to 2003, caudate lobectomy, including 19 cases of isolated lobectomy and 20 cases of combined lobectomy, were performed in 39 patients with HCC originating from caudate lobe, and the factors that might influence postoperative liver function were compared between the two groups.</p><p><b>RESULTS</b>All tumors were resected successfully. One patient died of postoperative renal failure. Hydrothorax occurred in 3 patients, ascites in 4 patients, and bile leakage in 1 patient. The survival rates of 1, 3, 5 year were 53%, 50%, 39% respectively.</p><p><b>CONCLUSIONS</b>Caudate lobectomy is a effective method for HCC originating from caudate lobe.</p>

The significance of liver hanging maneuver in liver-splitting anterior approach for hepatectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the feasibility of developing a tunnel between inferior vena cava (IVC) and caudate lobe before passing a tape through it, and to explore the significance of liver hanging maneuver in liver-splitting anterior approach for hepatectomy.</p><p><b>METHODS</b>Blunt dissection was used to develop the tunnel before a tape was passed through. A hemostatic plate was placed on the surface of liver parenchyma if needed. In the procedure of hepatectomy, the tape was pulled up to create an interspace between liver parenchyma and IVC so that the IVC can be protected during transection.</p><p><b>RESULTS</b>Liver hanging maneuver was performed successfully in 47 cases. There were no severe complications related to the procedure in these cases. The procedure was terminated in 1 case because of severe bleeding.</p><p><b>CONCLUSIONS</b>1. Liver hanging maneuver is feasible in terms of anatomy and technique. 2. With liver hanging maneuver, IVC can be protected safely and the intrahepatic vessels and ductal system at the transaction line can be exposed clearly. It also makes anterior approach for hepatectomy safer and easier.</p>

The study on immunomodulation of donor mesenchymal stem cells on discordant liver xenotransplantation / 中华外科杂志

<p><b>OBJECTIVE</b>To observe the influence of guinea pig mesenchymal stem cells (MSCs) culture in vitro on the immunological status in heterogeneous recipient, and to evaluate the immunomodulation of MSCs to the immune rejection of liver xenotransplantation.</p><p><b>METHODS</b>The mononuclear cell fraction obtained by centrifugation over Percoll was cultured in vitro. Cell surface epitopes were analyzed by flow cytometry technique, and MSCs were incubated at the addition of adipocyte induction media, and stained in Oil Red O. The immunoglobulin and complement in rat recipient serum were assayed after infusion of donor MSCs. Thirty guinea pigs and thirty Wistar rats were randomly divided into three groups. All rat recipients undertook cyclophosphamide (CTX) infusion. Group A was MSCs infusion group, group B was saline infusion group and group C was dexamethasone (DXM) infusion group. Orthotopic guinea pig to rat liver transplantation model was established. The survival time and the immunopathology of graft were observed.</p><p><b>RESULTS</b>According to flow cytometry assay, MSCs were positive for CD44 and CD29, while negative for CD34 and CD45. Lipid droplets were found in the MSCs cytoplasm after being incubated in adipogenic inducation media. The concentrations of IgG, IgM, C3 at all time point after MSCs infusion were significantly decreased than before (P < 0.05), while the concentrations of IgA and C4 did not changed. The survival time of group A (431 +/- 27 min) was obviously longer than group B (148 +/- 16 min) and group C (141 +/- 22 min) (P < 0.01). The intense hyperacute rejection rapidly occurred of group B and C after blood re-perfusion. The severe immunopathological injury could be observed at the grafts of group B and C. However, the hyperacute rejection of group A occurred slightly.</p><p><b>CONCLUSIONS</b>MSCs can be identified by virtue of cell morphology, membrane phenotype and differential potential. MSC may play a role in the immunosuppression in hyperacute rejection in the liver xenotransplantation.</p>

Retrograde caudate lobectomy in 7 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the clinical value and significance of retrograde caudate lobectomy.</p><p><b>METHODS</b>From December 2003 to January 2005, 7 patients underwent retrograde caudate lobectomy in which division and ligation of short hepatic veins were carried out at the final stage of the procedure in stead of at the initial stage.</p><p><b>RESULTS</b>The procedures were carried out smoothly with no operative death in all the 7 cases including isolated complete caudate lobectomy in 4 cases, isolated partial caudate lobectomy in 1 case, combined right half liver resection in 2 case. The average operation time, blood loss and length of stay after operation was (273 +/- 44) min, (1114 +/- 241) ml (800-1500 ml) and 16 days respectively. Complications including pleural effusion and ascites in 1 case respectively were fully recovered. During the follow-up, 1 patient died at 6 months for tumor recurrence in lung and the remaining 6 patients are alive at the follow-up of 5 to 16 months.</p><p><b>CONCLUSIONS</b>Retrograde caudate lobectomy is a new procedure suitable for those caudate neoplasms which are adhering to or infiltrating to IVC or too big to move side by side. The application of this technique can converse certain kind of caudate lobe tumor from non-resectable to resectable resulting in widening the indication.</p>

Diagnosis and treatment of vasoactive intestinal peptide-secreting-tumors: one case report and 15 years review in China / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the experiences of diagnosis and treatment for vasoactive intestinal peptide-secreting-tumors (VIPoma) by summarizing clinical informations of 15 patients with VIPoma.</p><p><b>METHODS</b>To analyze Clinical manifestations, laboratory examinations, imaging features, operation, pathological findings and follow up survey of 15 patients, among them 1 case from our hospital and the other 14 cases were searched in chinese biological and medical literature database from Jan 1987 to Dec 2002.</p><p><b>RESULTS</b>The main clinical manifestation include periodical secretory watery diarrhea, hypokalemia, achlorhydria, in addition, periodical backache, skin rash, and polyps of colon were presented in the case in our hospital. The immunohistochemical expression of many kinds of digestive hormone including VIP presented positive; All clinical symptoms of which except polyps disappeared after operation, elevated VIP data in serum also markedly decreased. Part resection of superior mesenteric vein was performed in the same patient.</p><p><b>CONCLUSIONS</b>VIPoma is rare. Typical symptoms and the serum value of VIP were keys to diagnosis, the operation is the most effective means for treatment. Resection of tumor, Radiofrequency tissue ablation, liver transplantation can be selected for metastatic VIPoma in the liver.</p>